Healthcare Provider Details

I. General information

NPI: 1720354426
Provider Name (Legal Business Name): GARY R HERNANDEZ LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AV.
FONTANA CA
92335
US

IV. Provider business mailing address

2020 IOWA AVE STE 101
RIVERSIDE CA
92507-0520
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2350
  • Fax:
Mailing address:
  • Phone: 951-235-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT36206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: